Contact Information Form for Field Trips

Contact Information Form for Field Trips

For use in the event of an emergency while on a field trip, please provide the following information:
Name:
Email:
example@example.com
Phone Number:
I am a Caltech:
Please describe your affiliation:
Field Trip Specifics
Purpose of Trip:
Please provide your course number:
Trip Purpose Description:
Instructor/Faculty Sponsor:
Dates of Field Trip:
Destination(s):
Emergency Contact Information
Emergency Contact Name:
Emergency Contact Address:
Emergency Contact Phone:
Emergency Contact Email:
Please provide the name of your medical insurance carrier and a policy number below.
Insurance Carrier:
Policy Number:
If you have a special health condition that an attending physician must know of in the case of an emergency, please provide the information in a sealed envelope to the supervising faculty member of your field trip. The faculty member will keep the sealed envelope until the trip is over and then return it back to you. In case of an emergency contact Caltech Security at 626-395-4701 , or extension 5000 from campus phones.

Confirmation and Submission

Confirmation of Guidelines
Please complete the individual check boxes listed below to verify that you have read through the field information shown on the Division field website:

(https://www.gps.caltech.edu/academics/field-trips).

Once you have read the information please confirm that you are aware of the provided information and agree with the following guidelines:
Please click this link to read the General Guidelines for Fieldwork in the GPS Division
I confirm I have read and agree to the General Guidelines for Fieldwork in the GPS Division
Please click this link to read the Heat Illness Guidelines
I confirm I have read and agree to the Heat Illness Guidelines
Please click this link to read the Valley Fever Risk & Prevention
I confirm I have read and agree to the Valley Fever Risk & Prevention Guidelines
Please click this link to read the Field Trip Alcohol Policy
I confirm I have read and agree to the Field Trip Alcohol Policy
Field Safety Plan
GPS Contact People:

Aleen Boladian: 626-395-6206
John Eiler: 626-395-6108
Heather Knutson: 626-395-4268
Jen Shechet: 626-395-6111

Click the “Submit” button below to submit this form electronically.

A copy of the form will be e-mailed to your e-mail address that you entered above.

All Contact Information Forms for Field Trips can also be submitted

in hard copy or over email to Mark Garcia.
Should be Empty:

Field Trip Specifics